Factors Associated With Physical Restraint in an Urban Emergency Department.

STUDY OBJECTIVE: To determine what patient characteristics were associated with the application of physical restraints in our emergency department (ED). METHODS: This was a retrospective analysis of encounters in the ED of an urban, Level I academic trauma center. We included ED encounters of adult patients (aged ≥18 years) during a 5-year period starting in 2017. We evaluated the independent association of restraint application during an encounter using a generalized estimating equation model. RESULTS: There were 464,031 ED encounters during the time period from 162,244 unique patients, including 34,798 (7.5%) with restraint application, comprising 18,166 unique patients. Several variables were associated with an increased likelihood of restraint use during an encounter. The variable with the highest odds ratio was intoxication with drugs or alcohol (adjusted odds ratio [aOR] 8.29; 95% confidence interval (CI) 7.94 to 8.65). American Indian race was associated with increased odds of restraint application (aOR 1.42; 95% CI 1.31 to 1.54) compared to the reference value of White race. Black race (aOR 0.58; 95% CI 0.55 to 0.61) and Hispanic ethnicity (aOR 0.42; 95% CI 0.37 to 0.48) were associated with lower odds of restraint application. CONCLUSIONS: Drug and alcohol intoxication were most closely associated with restraint. Encounters in which the patient was American Indian had higher odds of restraint, but this study does not replicate prior findings regarding other racial disparities in restraint.

Comparison of efficacy and frequency of akathisia and dystonia between olanzapine, metoclopramide and prochlorperazine in ED headache patients.

STUDY OBJECTIVE: To compare the efficacy and frequency of akathisia and dystonia between the dopamine antagonist headache medications olanzapine, metoclopramide and prochlorperazine. METHODS: This was a retrospective observational cohort study of patients presenting to a large urban level one trauma center between 2010 and 2018. Inclusion criteria was age ≥ 18 who presented to the emergency department with a chief complaint of headache who received either olanzapine, metoclopramide or prochlorperazine. The primary outcome was need for rescue medication. Secondary outcomes were receiving medication for either akathisia or dystonia. Logistic regression was used to identify differences between the three cohorts up to 72 h from initial presentation. RESULTS: There were 5643 patients who met inclusion criteria. Olanzapine was the most commonly used drug (n = 2994, 53%) followed by prochlorperazine (n = 2100, 37%) and metoclopramide (n = 549, 10%). After adjusting for age and gender, there were no differences in risk for receiving rescue therapy or developing akathisia or dystonia. CONCLUSION: During initial ED visit and up to 72 h after receiving olanzapine, metoclopramide or prochlorperazine, we found no difference in risk for requiring rescue medication or developing akathisia or dystonia.

The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial.

BACKGROUND: The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE: This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS: This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS: A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS: There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.

Cerebral oximetry monitoring using near-infrared spectroscopy during adult procedural sedation: a preliminary study.

BACKGROUND AND OBJECTIVES: We sought to evaluate the effect of adult procedural sedation on cerebral oxygenation measured by near-infrared spectroscopy (rSo2 levels), and to assess whether respiratory depression occurring during procedural sedation was associated with decreases in cerebral oxygenation. METHODS: We performed a prospective, observational preliminary study on a convenience sample of adult patients (>18 years) undergoing unscheduled procedural sedation in the ED from August 2017 to September 2018 at Hennepin County Medical Center in Minneapolis, Minnesota. The primary outcome measures were rSo2 values by level of sedation achieved and the incidence of cerebral hypoxaemia during procedural sedation (absolute rSo2 ≤60 or decrease ≥20% from baseline). The secondary outcome is the decrease in rSo2 during episodes of respiratory adverse events (AEs), defined by respiratory depression requiring supportive airway measures. RESULTS: We enrolled 100 patients (53% female). The median (IQR) rSo2 values (%) by each level of sedation achieved on the Observer Assessment of Alertness and Sedation (OAAS) scale 1-5, respectively, were 74 (69-79), 74 (70-79), 74 (69-79), 75 (69-80), 72 (68-76). The incidence of cerebral hypoxaemia at any point within the sedation (absolute rSo2 <60%) was 10/100 (10%); 2 out of 10 had rSo2 reduction more than 20% from baseline value; the median (IQR) observed minimum rSo2 in these patients was 58 (56-59). We observed respiratory depression in 65 patients via standard monitoring; of these, 39 (60%) required at least one supportive airway measure, meeting the definition of a respiratory AE. During these AEs, 15% (6/39) demonstrated cerebral hypoxaemia with a median (IQR) minimum rSo2 of 58 (57-59). Four patients (4%) had cerebral hypoxaemia without a respiratory AE. CONCLUSION: Cerebral oximetry may represent a useful tool for procedural sedation safety research to detect potential subclinical changes that may be associated with risk, but appears neither sensitive nor specific for routine use in clinical practice.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages.

STUDY OBJECTIVE: Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation. METHODS: This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0. RESULTS: We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%). CONCLUSION: We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.

Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update.

We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial.

STUDY OBJECTIVE: Hyperglycemia is commonly encountered in the ED; the importance of glucose reduction in patients well enough to be discharged is unknown. METHODS: We conducted a prospective, randomized trial of ED patients with hyperglycemia with a glucose value 400-600 mg/dL who were discharged from the ED, excluding those with type 1 diabetes mellitus. Patients were randomly assigned to a discharge glucose goal, <350 mg/dL (moderate control) or < 600 mg/dL (loose control). The primary outcome was ED length of stay. RESULTS: Among 110 enrolled patients, 57 were assigned to moderate and 53 to loose glycemic control. Median (IQR) length of stay was 211 min (177-288 min) for the moderate group and 216 min (151-269 min) for the loose group (difference, 17 min [95% CI -15 to 49 min]). ED length of stay for those with an actual discharge glucose <350 mg/dL was 29 min longer (95% CI -1 to 59 min). Repeat ED visits for hyperglycemia (7% vs 6%), hospitalization for hyperglycemia (0% vs 2%), and hospitalization for any reason (4% vs 8%) did not differ significantly between groups. CONCLUSION: In the intention-to-treat analysis, ED length of stay and 7-day outcomes were not significantly different whether moderate or loose glycemic control was pursued. However, the length of stay for those with discharge glucose <350 mg/dL was approximately 29 min longer. ED glycemic control did not appear to be associated negative short-term outcomes. Glucose reduction in well-appearing ED patients may consume time and resources without conferring short- or long-term benefits. TRIAL REGISTRATION: Clinicaltrials.govNCT02478190.

The Characteristics and Prevalence of Agitation in an Urban County Emergency Department.

STUDY OBJECTIVE: We seek to determine the characteristics and prevalence of agitation among patients in an urban county emergency department (ED). METHODS: This was a prospective observational study of ED patients at an urban Level I trauma center. All ED patients were screened during daily randomized 8-hour enrollment periods. Adult agitated patients, defined as having an altered mental status score greater than 1, were included. Trained research volunteers collected demographics and baseline data, including the presenting altered mental status score, use and type of restraints, and whether any initial sedative was given. The altered mental status score, vital signs, and any medications or treatments given were recorded every 5 minutes thereafter until the patient had an altered mental status score less than 1. Providers were asked to describe clinical events resulting in an intervention occurring during the patient course, including hypotension, vomiting, increased monitoring, use of supplemental oxygen or airway adjunct, or intubation. The provider also completed a checklist to determine the presence of delirium symptoms. RESULTS: A total of 43,838 patients were screened (45.1% women; median age 33 years; range 0 to 102 years). The prevalence of agitation was 2.6% (1,146/43,838; median altered mental status score 2). Of these patients, 84% (969/1,146) required physical restraint and 72% (829/1,146) required sedation with an intramuscular injection. Sedative agents were olanzapine in 39% of patients (442/1,146), droperidol in 20% (224/1,146), haloperidol in 20% (226/1,146), a benzodiazepine in 6% (68/1,146), and ketamine in 5% (52/1,146). Delirium characteristics were observed in 0.6% of patients (260/43,838), representing 23% of agitated patients in the ED. Clinical events were observed in 13% of agitated patients (114/866) without delirium symptoms and 26% (68/260) with delirium symptoms. Characteristics associated with a clinical event included delirium symptoms (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.4), a cause related to a drug other than alcohol (OR 1.7; 95% CI 1.1 to 2.9), or a nondrug-induced cause of agitation (OR 3.5; 95% CI 2.3 to 5.6). CONCLUSION: The prevalence of agitation in the ED was 2.6%. Agitated patients frequently required restraint and sedation, with significant rates of clinical events requiring intervention.

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department.

STUDY OBJECTIVE: Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation. METHODS: This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale. RESULTS: Seven hundred thirty-seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale <1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI -1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI -3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group. CONCLUSION: Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.

Sufentanil sublingual tablet 30mcg for moderate-to-severe acute pain in the ED.

BACKGROUND: Pharmacological properties of the sufentanil sublingual tablet 30mcg (SST 30mcg) could offer potential analgesic advantages in settings requiring noninvasive, acute pain management. The feasibility of using SST 30mcg for moderate-to-severe pain management in the emergency department (ED) was evaluated. METHODS: This open-label, multicenter feasibility study included patients aged ≥18years who presented to the ED with moderate-to-severe pain (≥4 on the numeric rating scale of pain intensity (NRS); opioid-tolerant patients were excluded. Patients received a single SST 30-mcg dose (single-dose cohort) or, upon request, ≤3 additional doses ≥60min apart (multiple-dose cohort) and were evaluated over 1 or 2h. Effectiveness was assessed by patient-reported pain scores (11-point NRS; 5-point pain relief scale). Safety and tolerability were also assessed. RESULTS: Overall, 76 patients enrolled into the single-dose (n=40) and multiple-dose (n=36) cohorts. In the first hour (combined cohorts), mean pain intensity was significantly lower 15-min post-dosing (P<0.001; clinically meaningful within 30-minutes post-dosing) and continued to decrease during the first hour (P<0.001 for each 15-minute interval). Mean pain intensity (multiple-dose cohort) decreased from 7.6 at baseline to 4.5 at 1h and to 4.6 at 2h (P<0.001 for both); mean pain relief increased from baseline to 1.9 at 1h (P<0.001) and to 2.0 at 2h (P<0.001). Most (79%) patients had no adverse events (AEs), and there were no severe AEs. CONCLUSIONS: SST 30mcg was feasible for managing moderate-to-severe acute pain in an ED setting.

The occurrence of aspiration pneumonia after emergency endotracheal intubation.

STUDY OBJECTIVE: Adverse events, including aspiration, occur during Emergency Department (ED) intubation, but their contemporary incidence is not well described. We sought to estimate the rate of aspiration pneumonia potentially related to emergency intubation. METHODS: We conducted a prospective observational study of adult patients who were endotracheally intubated in the ED. Using a standard definition, we determined the proportion of patients who developed aspiration pneumonia after intubation. Aspiration pneumonia was defined as any of the following in patients without a diagnosis of community acquired pneumonia, healthcare-associated pneumonia, or aspiration prior to intubation: pathogenic growth in sputum culture, unexplained hypoxemia, or radiographic evidence of pneumonia in the first 48h after intubation. Baseline characteristics and intubation details were compared for those with and without aspiration pneumonia. RESULTS: 879 patients were enrolled over a 30-month period. Intubation was facilitated by video laryngoscopy (49%), direct laryngoscopy (45%), nasal intubation (4%), a intubating laryngeal mask airway (1%), and a surgical airway (0.1%). 85% were intubated on the first attempt, 12% on the second, 3% on the third or more attempts. 25% of patients experienced an oxygen saturation <90% during the intubation. After excluding patients not eligible for the outcome assessment (those who died within 48h without findings of pneumonia), 66/823 (8%) developed aspiration pneumonia potentially related to ED intubation. In comparing those with and without aspiration pneumonia, there were no differences between first intubation attempt parameters and the occurrence of aspiration pneumonia. CONCLUSION: Aspiration pneumonia occurred commonly in this cohort. Although we did not identify any intubation factors that differed between those with and without with aspiration pneumonia, these findings should remind emergency physicians that emergency endotracheal intubation remains a high-risk procedure, and all care should be taken to minimize the risk of peri-intubation complications.

Emergency department length of stay for ethanol intoxication encounters.

BACKGROUND: Emergency Department (ED) encounters for ethanol intoxication are becoming increasingly common. The purpose of this study was to explore factors associated with ED length of stay (LOS) for ethanol intoxication encounters. METHODS: This was a multi-center, retrospective, observational study of patients presenting to the ED for ethanol intoxication. Data were abstracted from the electronic medical record. To explore factors associated with ED LOS, we created a mixed-effects generalized linear model. RESULTS: We identified 18,664 eligible patients from 6 different EDs during the study period (2012-2016). The median age was 37years, 69% were male, and the median ethanol concentration was 213mg/dL. Median LOS was 348min (range 43-1658). Using a mixed-effects generalized linear model, independent variables associated with a significant increase in ED LOS included use of parenteral sedation (beta=0.30, increase in LOS=34%), laboratory testing (beta=0.21, increase in LOS=23%), as well as the hour of arrival to the ED, such that patients arriving to the ED during evening hours (between 18:00 and midnight) had up to an 86% increase in LOS. Variables not significantly associated with an increase in LOS included age, gender, ethanol concentration, psychiatric disposition, using the ED frequently for ethanol intoxication, CT use, and daily ED volume. CONCLUSION: Variables such as diagnostic testing, treatments, and hour of arrival may influence ED LOS in patients with acute ethanol intoxication. Identification and further exploration of these factors may assist in developing hospital and community based improvements to modify LOS in this population.

A brief assessment of capacity to consent instrument in acutely intoxicated emergency department patients.

OBJECTIVE: The aim of this study was to determine to what extent acute alcohol intoxication effects capacity to assent, consent, or refuse research participation. METHODS: This was a prospective, observation study performed at our inner city, county hospital with >100,000 annual emergency department visits. Non-pregnant, English speaking patients older than 18 with evidence of acute alcohol intoxication were considered eligible. After medical screening, a trained research associate presented the study version of the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) tool. The primary outcome was the number of patients able to correctly respond to all 10 questions. RESULTS: Of 642 screened patients, 415 patients were enrolled and completed the tool. The mean alcohol concentration was 227mg/dL (range 25-500mg/dL). Sixteen patients (3.9%) answered all 10 questions correctly; by definition of the UBACC, these patients were deemed to possess capacity to consent. Mean alcohol concentrations in the capacity group were lower than in those lacking capacity; 182mg/dL (SD 6.7) versus 229mg/dL, (SD 7.9). Of the 287 patients who were interviewed upon sobriety at discharge, 182 patients (63.4%) did not recall completing the questionnaire. CONCLUSIONS: While intoxicated emergency department patients are able to complete the questionnaire, the majority do not possess capacity to provide informed consent to research. A minority of participants remember involvement once they have achieved sobriety, exception from informed consent protocols are needed to perform emergency research in this population.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Importance: The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. Objective: To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. Design, Setting, and Patients: The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Interventions: Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). Main Outcomes and Measures: The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Results: Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. Conclusions and Relevance: In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. Trial Registration: clinicaltrials.gov Identifier: NCT02902146.

Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department.

STUDY OBJECTIVE: Parenteral olanzapine is an emerging therapy for a variety of conditions in the emergency department (ED). Intramuscular administration is standard; however, intravenous administration has been proposed as a safe alternative route. We investigate the safety and efficacy of both intramuscular and intravenous olanzapine in the ED when used for a variety of indications. METHODS: This was a prospective observational study of patients presenting to an urban Level I trauma center ED. Trained research associates screened the ED for patients receiving parenteral olanzapine. The primary outcome of the study was incidence of respiratory depression measured with standard markers. Secondary outcomes included use of additional doses or sedatives, corrected QT interval (QTc) data, time to nadir sedation, adverse events, and physician assessment of efficacy. RESULTS: There were 784 patients included in the final analysis. Intravenous olanzapine was administered to 295 patients; 489 received intramuscular olanzapine. Respiratory depression occurred in 11 of 295 patients (3.7%; 95% confidence interval [CI] 1.6% to 5.9%) receiving intravenous olanzapine and 10 of 489 (2.0%; 95% CI 0.8% to 3.3%) receiving intramuscular olanzapine. Seven patients required intubation, 2 in the intravenous group and 5 in the intramuscular group. Nonrespiratory complications occurred in 8 patients, 6 of 295 (2.0%; 95% CI 0.4% to 3.6%) in the intravenous group and 2 of 489 (0.4%; 95% CI 0% to 0.96%) in the intramuscular group. Dysrhythmias were isolated to 2 episodes of bradycardia requiring only supportive care. CONCLUSION: These data suggest that, with proper monitoring, administration of olanzapine, both intramuscular and intravenous, is safe for several indications in the ED.

Effect of Body-Worn Cameras on EMS Documentation Accuracy: A Pilot Study.

INTRODUCTION: Current Emergency Medical Services (EMS) documentation practices usually occur from memory after an event is over. While this practice is fairly standard, it is unclear if it can introduce significant error. Modern technology has seen the increased use of recorded video by society to more objectively document notable events. Stationary mounted cameras, cell-phone cameras, and law enforcement officer Body-Worn Cameras (BWCs) are increasingly used by society for this purpose. Video used in this way can often clarify or contradict recall from memory. BWCs are currently not widely used by EMS. The hypothesis is that current EMS documentation practices are inaccurate and that BWCs will have a positive effect on documentation accuracy. METHODS: This prospective, observational study used a convenience sample of paramedics in a simulation lab. The Paramedics wore a BWC and responded to a simulated call of "One Down" (unresponsive from heroin abuse) involving Role Players (RPs). The paramedics received standardized cues from the RPs during the simulation to keep it on track.  The simulation contained many factors of concern (e.g., weapons and drugs in plain view, unattended minors, etc.) and intentional stressors (e.g., distraught family member, uncooperative patient, etc.). Upon completion of the scenario, paramedic documentation occurred from memory on an electronic template.  After initial documentation, paramedics viewed their BWC recording and were allowed to make tabulated changes. Changes were categorized by a priori criteria as minor, moderate, or major. RESULTS: Ten paramedics participated with an average age of 33.3 years (range 22-43), 8 males and 2 females. The average length of paramedic career experience was 7.7 years (range 2 months to 20 years). There were 71 total documentation changes (7 minor, 51 moderate, 13 major) made after video review. Linear regression (ANCOVA) indicated changes made indirectly correlated with years of experience (coefficient 8.27, 4.22-12.3, 95% CI, p = 0.002), but all made some changes. CONCLUSION: Current EMS documentation practices demonstrate significant inaccuracy regardless of years of experience. Use of BWC technology appears to significantly improve EMS documentation accuracy in this pilot study.

Randomized clinical trial of propofol versus alfentanil for moderate procedural sedation in the emergency department.

STUDY OBJECTIVE: To compare the frequency of airway and respiratory adverse events leading to an intervention between moderate sedation using alfentanil or propofol. METHODS: We performed a randomized clinical trial in which adults undergoing moderate sedation in the ED received either alfentanil or propofol. Our primary outcome was the frequency of airway and respiratory adverse events leading to an intervention. Other outcomes included sedation depth, efficacy, sedation time, patient satisfaction, pain, and satisfaction. RESULTS: 108 subjects completed the trial: 52 receiving alfentanil and 56 receiving propofol. Airway or respiratory adverse events leading to an intervention were similar between the two groups: 23% for alfentanil and 20% for propofol (p=0.657). There were no serious adverse events in any group. Secondary outcomes were notably different in the rate of reported pain (48% for alfentanil, 13% for propofol) and recall (75% for alfentanil, 23% for propofol) and similar in the rate of satisfaction with the procedure (87% for alfentanil, 84% for propofol). CONCLUSION: We found a similar frequency of airway and respiratory adverse events leading to intervention between alfentanil and propofol used for moderate procedural sedation. Both agents appear safe for moderate procedural sedation.